Who needs research?

Here’s a wonderful article on the debate about whether alternative medicine works and the view of it in mainstream medicine, alternative medicine, politics, science and from its detractors. What seems so hard to believe is that no form of research proves how efficacious alternative therapy is. All alternative practitioners see in their practice day in day out how people come in with both chronic and acute conditions and get significantly better in a relatively short period of time. All the clients who come for the treatments experience this too, otherwise they wouldn’t carry on coming back nor recommend it. The public are not fools. They want something that works and will pay for it if it does. So why is there no form of research that shows how remarkable alternative therapy is. In particular craniosacral therapy. If anyone has any experience around research and has any ideas how research could be created that would show how deeply it effects the body I would be very interested in helping bring together a research programme. In particular if anyone has any access to some of the new CT scanners that could measure the response in the body while being treated, that would be particularly exciting. Anyway here’s the article which runs to several pages. Click on the link at the end to continue on (thanks Jeanne for sending this on to me).

The Triumph of New-Age Medicine

Medicine has long decried acupuncture, homeopathy, and the like as dangerous nonsense that preys on the gullible. Again and again, carefully controlled studies have shown alternative medicine to work no better than a placebo. But now many doctors admit that alternative medicine often seems to do a better job of making patients well, and at a much lower cost, than mainstream care—and they’re trying to learn from it.

I MEET BRIAN BERMAN, a physician of gentle and upbeat demeanor, outside the stately Greek columns that form the facade of one of the nation’s oldest medical-lecture halls, at the edge of the University of Maryland Medical Center in downtown Baltimore. The research center that Berman directs sits next door, in a much smaller, plainer, but still venerable-looking two-story brick building. A staff of 33 works there, including several physician-researchers and practitioner-researchers, funded in part by $35 million in grants over the past 14 years from the National Institutes of Health, which has named the clinic a Research Center of Excellence. In addition to conducting research, the center provides medical care. Indeed, some patients wait as long as two months to begin treatment there—referrals from physicians all across the medical center have grown beyond the staff’s capacity. “That’s a big change,” says Berman, laughing. “We used to have trouble getting any physicians here to take us seriously.”

The Center for Integrative Medicine, Berman’s clinic, is focused on alternative medicine, sometimes known as “complementary” or “holistic” medicine. There’s no official list of what alternative medicine actually comprises, but treatments falling under the umbrella typically include acupuncture, homeopathy (the administration of a glass of water supposedly containing the undetectable remnants of various semi-toxic substances), chiropractic, herbal medicine, Reiki (“laying on of hands,” or “energy therapy”), meditation (now often called “mindfulness”), massage, aromatherapy, hypnosis, Ayurveda (a traditional medical practice originating in India), and several other treatments not normally prescribed by mainstream doctors. The term integrative medicinerefers to the conjunction of these practices with mainstream medical care.

Berman’s clinic is hardly unique. In recent years, integrative medical-research clinics have been springing up all around the country, 42 of them at major academic medical institutions including Harvard, Yale, Duke, the University of California at San Francisco, and the Mayo Clinic. Most appear to be backed enthusiastically by administrators and many physicians. “Doctors tend to end up trained in silos of specialization,” says Jay Perman, president of the University of Maryland at Baltimore and a practicing pediatrician. “We’re taught to make a diagnosis, prescribe a therapy, and we’re done. But we’re not done. The patient’s environment matters. When it comes to alternative medicine, it’s not clear what the mechanism is that can make it helpful to patients, but it may be that it helps create the right environment.”

At one of the University of Maryland Medical Center’s hospitals, I introduced myself to Frank Corasaniti, a 60-year-old retired firefighter who had come in for an acupuncture treatment from Lixing Lao, a Ph.D. physiologist with Berman’s center. Corasaniti had injured his back falling down a steel staircase at a firehouse some 20 years earlier, and had subsequently injured both shoulders and his neck in the line of duty. Four surgeries, including one that fused the vertebrae in his neck, followed by regimens of steroid injections and painkillers, had only left him in increasing pain. He retired from the fire department in 2002 and took a less physically demanding job with Home Depot, but by last year his sharpening pain made even that work too difficult, and he gave it up. “I was starting to think I’d have to stop doing everything,” he told me. He was particularly worried that he’d be unable to continue helping out his mother, who had been battling cancer for two years.

His wife, a nurse, urged him to try acupuncture, and in February, with the blessing of his doctor, he finally met with Lao, who had trained in his native China as an acupuncturist. Their first visit had lasted well over an hour, Corasaniti says, time mostly spent discussing every aspect of his injuries and what seemed to ease or exacerbate them, and also other aspects of his health—he had been gaining weight, he was constipated, he was developing urinary problems. They talked at length about his diet, his physical activity, his responsibilities and how they weighed on him. Lao focused in on stress—what was causing it in Corasaniti’s life, and how did it aggravate the pain?—and they discussed the importance of finding ways to relax in everyday life.

Then Lao had explained how acupuncture would open blocked “energy pathways” in his body, allowing a more normal flow of energy that would lessen his pain and help restore general health. While soothing music played, Lao placed needles in and around the areas where Corasaniti felt pain, and also in his hands and legs, explaining that the energy pathways affecting him ran throughout his body. The needle emplacement itself took only about three minutes. Lao then asked Corasaniti to lie quietly for a while, and Corasaniti promptly fell asleep, awakening about 20 minutes later when Lao gently roused him. Corasaniti continued to come in for 40-minute sessions twice a week for six weeks, and since then had been coming in once a week.

Though of course alternative-medicine experiences can vary widely, certain aspects of Corasaniti’s visit are typical. These include a long initial meeting covering many details of the patient’s history; a calming atmosphere; an extensive discussion of how to improve diet and exercise; a strong focus on reducing everyday stress; an explanation of how the treatment will unleash the body’s ability to heal itself; assurance that over time the treatment will help both the problem that prompted the visit and also general health; gentle physical contact; and the establishment of frequent follow-up visits.

Corasaniti’s description of the results is fairly typical too. After two months of treatment, the worst area of pain, near his neck, had shrunk from a circle six inches across to the size of quarter, he said. He’d lost 10 pounds, and his constipation and urinary difficulties had cleared up. And because of his progress, he’d been cleared by his doctor to start a vigorous monitored-exercise program aimed at strengthening muscles in a way that should reduce the chances of reinjury, in addition to improving his general fitness. “I just feel so much better,” he said.

“IT’S CLEVERLY MARKETED, dangerous quackery,” says Steven Salzberg, a prominent biology researcher at the University of Maryland at College Park, an easy commuter-rail ride from the medical center. “These clinics throw together a little homeopathy, a little meditation, a little voodoo, and then they add in a little accepted medicine and call it integrative medicine, so there’s less criticism. There’s only one type of medicine, and that’s medicine whose treatments have been proven to work. When something works, it’s not all that hard to prove it. These people have been trying to prove their alternative treatments work for years, and they can’t do it. But they won’t admit it and move on. Of course they won’t. They’re making too much money on it.”

On his well-read blog and elsewhere, Salzberg has established himself as an expert on research studies related to alternative medicine—and as one of the angriest voices attacking the field. In particular, he calls for an end to government funding of clinics like Berman’s. He says the funding is in no way based on any genuine belief among scientists that alternative medicine merits further study. Rather, it is propelled by a handful of members of Congress—most notably Tom Harkin of Iowa, the chair of the Senate subcommittee that oversees NIH funding—who are determined to see their own misplaced faith in alternative medicine validated. (Harkin’s office declined to make him available for an interview.)

Medical centers are lining up to establish research clinics so that they can take NIH funding for alternative-medicine studies, Salzberg adds. Aggressive marketing of these clinics can also generate substantial patient demand (even a small integrative clinic can take in several million dollars a year). The anecdotal testimony these patients offer merely reflects their gullibility and self-selection into alternative care; subjective symptoms like pain and discomfort, he notes, are susceptible to the power of suggestion. These same symptoms also tend to be cyclical, meaning that people who see a practitioner when their symptoms flare up are likely to see the symptoms moderate, no matter what the practitioner does or doesn’t do. Patients simply misattribute the improvement to the treatment.

Alternative medicine wouldn’t be quite so bad if it were harmless, Salzberg says, but it isn’t. “If the treatment is herbal tea or yoga, fine; it won’t help, but at least it won’t hurt you,” he says. “But acupuncture carries a real risk of infection from needles. And when a chiropractor cracks your neck, there’s a small but nontrivial chance that he can shear an artery in your neck, and you’ll die.” (A British Medical Journal study last year found that only 200 cases of likely acupuncture-related infection have been reported globally, but that many more may have occurred. Evidence for a tiny risk of chiropractic artery-shearing and related stroke is scant, indirect, and contested, but seems plausible.) The biggest danger of all, Salzberg adds, is that patients who see alternative practitioners will stop getting mainstream care altogether. “The more time they spend getting fraudulent treatments, the less time they’ll spend getting treatments that work and that could save their lives.”

It’s not hard to see alternative medicine as a dubious business, or even, in some part, a scam, if one includes all the supplements, devices, and patently absurd therapies that are hawked in magazines and infomercials and at strip malls. Anyone can make vague health claims for almost any reasonably safe product or practice with the appropriate fine print—“The U.S. Food and Drug Administration has neither evaluated nor approved the claims for this product,” for instance. And so the public snatches up millions of hologrammed silicone bracelets that promise to revitalize the fatigued.

Most homeopaths, acupuncturists, and herbalists don’t have an M.D. and don’t work under the close supervision of a physician, so they are free to make exaggerated claims or offer ungrounded advice. It’s difficult to get too worked up about teenagers dropping 20 bucks on a hip but medically useless bracelet, but we should all feel uncomfortable hearing about young children with autism being pulled out of behavioral therapy and placed into herbal or spinal-manipulation treatment. About 40 percent of Americans have tried some form of alternative medicine at some point, and some $35 billion a year is spent on it. A certain amount of abuse seems like a given.

Concerns of outright malpractice or naked hucksterism seem grossly misplaced when applied to a clinic like Berman’s. Nonetheless, says Salzberg, the bottom line is that studies clearly show alternative medicine simply doesn’t work. And at first glance, that contention seems nearly incontrovertible. The scientific literature is replete with careful studies that show, again and again, that virtually all of the core treatments plied by alternative practitioners, including homeopathy, acupuncture, chiropractic, and others, help patients no more than do “sham” treatments designed to fool patients into thinking they’re getting the treatment when they’re really not. (Even acupuncture can be faked, by tapping the skin in random places with a metal tube; reliably, these taps produce treatment results identical to those of the needles themselves.) “Acupuncture is just a 3,000-year-old relative of bloodletting,” Salzberg told me.

YOU MIGHT THINK the weight of the clinical evidence would close the case on alternative medicine, at least in the eyes of mainstream physicians and scientists who aren’t in a position to make a buck on it. Yet many extremely well-credentialed scientists and physicians with no skin in the game take issue with the black-and-white view espoused by Salzberg and other critics. And on balance, the medical community seems to be growing more open to alternative medicine’s possibilities, not less.

That’s in large part because mainstream medicine itself is failing. “Modern medicine was formed around successes in fighting infectious disease,” says Elizabeth Blackburn, a biologist at the University of California at San Francisco and a Nobel laureate. “Infectious agents were the big sources of disease and mortality, up until the last century. We could find out what the agent was in a sick patient and attack the agent medically.” To a large degree, the medical infrastructure we have today was designed with infectious agents in mind. Physician training and practices, hospitals, the pharmaceutical industry, and health insurance all were built around the model of running tests on sick patients to determine which drug or surgical procedure would best deal with some discrete offending agent. The system works very well for that original purpose, against even the most challenging of these agents—as the taming of the AIDS virus attests.

But medicine’s triumph over infectious disease brought to the fore the so-called chronic, complex diseases—heart disease, cancer, diabetes, Alzheimer’s, and other illnesses without a clear causal agent. Now that we live longer, these typically late-developing diseases have become by far our biggest killers. Heart disease, prostate cancer, breast cancer, diabetes, obesity, and other chronic diseases now account for three-quarters of our health-care spending. “We face an entirely different set of big medical challenges today,” says Blackburn. “But we haven’t rethought the way we fight illness.” That is, the medical establishment still waits for us to develop some sign of one of these illnesses, then seeks to treat us with drugs and surgery.

Unfortunately, the drugs we’ve thrown at these complex illnesses are by and large inadequate or worse, as has been thoroughly documented in the medical literature. The list of much-hyped and in some cases heavily prescribed drugs that have failed to do much to combat complex diseases, while presenting a real risk of horrific side effects, is a long one, including Avastin for cancer (blood clots, heart failure, and bowel perforation), Avandia for diabetes (heart attacks), and torcetrapib for heart disease (death). In many cases, the drugs used to treat the most-serious cancers add mere months to patients’ lives, often at significant cost to quality of life. No drug has proved safe and effective against Alzheimer’s, nor in combating obesity, which significantly raises the risk of all complex diseases. Even cholesterol-lowering statins, which once seemed one of the few nearly unqualified successes against complex disease, are now regarded as of questionable benefit in lowering the risk of a first heart attack, the use for which they are most widely prescribed. Surgery, widely enlisted against heart disease, is proving nearly as disappointing. Recent studies have shown heart-bypass surgery and the emplacement of stents to prop open arteries to be of surprisingly little help in extending the lives of most patients.

It doesn’t help that some of these treatments are foisted on people who don’t need them. According to one study, a person who shows up at an emergency room complaining of chest pain has about an 80 percent chance of being admitted and subjected to a series of sophisticated tests, even when the patient is not at high risk for heart disease and thus has an almost negligible chance of actually being ill if a few routine tests don’t turn up any irregularities. The longer round of tests carries a significant chance of falsely indicating that a key artery is clogged, and sometimes leads to the utterly unnecessary surgical insertion of a stent, accompanied by a long-term drug regimen to fight off the real risk of clotting in that stent. In this way, many healthy people each year are converted into long-term patients.

All of these shortcomings add up to a grim reality: as a prominent 2000 study showed, America spends vastly more on health as a percentage of gross domestic product than every other country—40 percent more than France, the fourth-biggest payer. Yet while France was ranked No. 1 in health-care effectiveness and other major measures, the United States ranked 37th, near the bottom of all industrialized countries.

7 comments

I hear you are in Toronto this weekend. Welcome to our city! I am a RCST/BCST practicing here who is very much interested bringing the research that does exist regarding Biodynamic Craniosacral to the surface. While I cannot offer CT scanners, I think a good place to start might be creating a database for RCST/BCST graduates to share the abstracts of their research projects. This is something I am hoping to compile and post on my website (www.cranialnerd.com) in the upcoming months. I think that there is a lot more research out there than we are aware of, it is just accessing that information that is the trick!

I agree, employing proper research methods is essential for Craniosacral to gain recognition in the mainstream medical community as a valid therapy that produces positive results. In order to employ proper research, we will need a fair number of practitioners and participants to create control groups and (of course) funding. Any ideas? I have some experience conducting research and would also love to be involved in participating in a research program. If this project begins to unfold further, please let me know.

hi emily, thanks for your feedback. pity we didnt meet up last week when i was there as it would have been good to talk face to face about your ideas around research. i think compiling research projects is a great idea and like you i suspect there is a lot out there in different corners of the field. i did one in london with the university of westminster quite a few years back and used all the practitioners at the clinic. happy to send that to you. will keep you posted around the research. it could be i have a way of funding it and i think what would be really useful is to have a pilot team who can come together and make sure meaningful research is carried out. there are plenty of practitioners we can go out to for the results. im in toronto in early nov so lets try and meet up then. best wishes, ged

Hi, I’m interested in getting more research out there on craniosacral therapy. I know someone at Warwick University is conducting a research study at the moment. I have offered my services at a pain clinic and was asked about using outcomes questionnaires. I am still waiting to hear if this is going ahead. Some info also from Westminster University about this I could send you, which recommends outcomes research if I remember rightly.

hi alison, would be interested in the outcomes research if you can send it over. i have conducted a research project with Univ Westminster in the past but maybe its something i havent seen. many thanks, ged

Hi, This is slightly off topic but I have just this weekend been to a discussion on why evidence based practice is needed but is only slowly happening in massage – but this discussion would be just as valid for cst. As I understand it the bottom line is that the model that the west currently uses to test the relevance of a therapy is evidence based – rather than clinical based. These are quite different, which explains why anecdotal evidence and client reports of wellbeing get refuted and are considered inadequate as “proof”.The biomedical model frames its enquiry on factors that can be easily measured within the lab.(These are predominately visual e.g. x-rays / MRIs etc, performance based (ROMs) or chemical.) One would think massage could perform pretty well in this criteria, but the RCT (random controlled tests) are so rigorous, it is inevitably “proven” that massage is ineffective for any therapeutic outcome.
However if we reframed the measurement tool to a biopsychosocial model, a far greater range and scope could be used. The problem though is that this is less valued by the medial fraternity and by it’s very design, admits to the variances that come when working with human “beings” as opposed to human machines.
CST (even more than massage perhaps) is working with “stuff” outside of conventional medicine. I believe that many of the changes occuring within clients’ systems are out of the current range of measurement tools. Science is only just starting to understand / explain what many instinctively work with…and is many years away from measuring it.
So – if we are to be taken seriously, the biopsychosoical model would seem our best bet for now. It uses a more holistic approach and while still limited in application, gives far more depth to the measurement of client response – and far more scope for research. It still has a component of “bio” so some medical tests can still be applied but looks at the whole person response.
I think if I was investing time and $ in research – that is the model I would use for now.

hi tish, thanks for your response. i couldnt agree more. its important to know who you are doing the research for and why. do you know anyone who could be the organizer of such a research programme. happy to work with them and utilize the BCST community im in touch with . ged

I agree Tish, I think much of what happens in a BCST session is very unique and individual to the person being treated on that particular day, making it difficult to standardise treatment as RCT need.
I am a physiotherapist (originally from Oz) studying at CTET London at the moment. Physiotherapy as a profession has in recent years built up a better base of evidence based practise research by enlisting data collection from nation-wide or even international practitioners compiling results to build statistically significant sample groups. Insurance companies really want that these days to fund anything. We need to try and do the same with CST to start to show some evidence to support what we know works.
When I have qualified I would love to be involved in some kind of research to help validate and promote the use of BCST. Personally I was incredibly aided following a dural tear with 3 sessions of BCST. Research needs to be broken into very specific measurable chunks, not big general questions. My aim in the future would be to start with something very specific like a longitudinal study of a patient group post dural tear. They could be their own controls with CST starting after say 6 months and symptoms monitored by a standardised questionnaire pre and post treatment. Very specific to the primary respiratory mechanism, of course BCST applies to the whole body but I think research like this, if shown to be efficacious would start to build awareness in the medical field.
Before embarking on the hard road of research it is imperative to be talking to statisticians/uni research teams to ensure efforts are in the right direction from the get go. If the methodology / plan is not valid for any reason the quality of the research will not be high. Anecdotal evidence is poor, you need to show statistically significant numbers of improvement for x to show that a treatment is robust enough to be seen as ‘proven’.
The way physiotherapy (for example) is building up more evidence is having a nation wide arrangement, where practitioners who volunteer to participate agree to submit data for say whiplash patients.
They fill out and submit questionnaires / treatment information for patients relevant to the study group as they present, only a small amount of work for individual practitioners, but gaining a large input of sample size overall from lots of contributors.